APPLICATION FOR CERTIFIED BANKRUPTCY ASSISTANT

Please complete the application in its entirety and comply with all of its instructions. If you have any questions, please email Dorothy Clay at claydo4@yahoo.com.

I. GENERAL INFORMATION

An * indicates a required response.

First Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

IF YOU ARE RECERTIFYING SKIP TO V (RECERTIFICATION)

II. LEGAL EMPLOYMENT

Current Employer *

Start Date (mm/yyyy) *

Street Address *

City *

State *

Zip Code *

Title (Position) *

Phone Number *

Previous Employer

Start Date (mm/yyyy)

End Date (mm/yyyy)

Street Address

City

State

Zip Code

Title (Position)

Phone Number

Previous Employer

Start Date (mm/yyyy)

End Date (mm/yyyy)

Street Address

City

State

Zip Code

Title (Position)

Phone Number

III. EDUCATION/CERTIFICATIONS

College or Law School Attended

From

Degree

College or Law School Attended

From

Degree

List any certifications.

Subject/Certification Granted

State

Date of Certification (mm/yyyy)

Subject/Certification Granted

State

Date of Certification (mm/yyyy)

How long has applicant worked in the bankruptcy field?

Years *

IV. REFERENCES

Name bankruptcy attorney(s) familiar with applicant's work. The CBA Committee reserves the right to contact the attorney/employer for verification of all information provided by the applicant.

Reference 1

First Name

Last Name

Company Name

Phone Number

Street Address

City

State

Zip Code

Reference 2

First Name

Last Name

Company Name

Phone Number

Street Address

City

State

Zip Code

V. RECERTIFICATION

IF CERTIFICATION HAS EXPIRED WITHIN 4 YEARS OF LAST CERTIFICATION, APPLICANT IS REQUIRED TO ATTEND THE CBA PROGRAM. NO EXAM WILL BE REQUIRED.

Are you recertifying? *

Yes

VI. COVENANTS

Please open the attached pdf to review.

Written Disclosure, Use of Program Materials and Rules & Regulations

https://fs22.formsite.com/abja/images/Application_Covenants.pdf

Acceptance and Acknowledgement *

I agree that I have read the Application Covenants document containing the Written Disclosure, Agreement Regarding use of CBA Program Materials, and Rules and Regulations

/s/ Applicant's Electronic Signature (by typing name)

Date (mm/dd/yyyy)

/s/ Supervisor's Electronic Signature (by typing name)

Date (mm/dd/yyyy)